Review Article

Helicobacter pylori Infection in the general population: A Middle Eastern perspective Hossein Khedmat (MD) 1 Reza Karbasi-Afshar (MD) *2 Shahram Agah (MD) 3 Saeed Taheri (MD) 4

1- Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqiyatallah University of Medical Sciences, Tehran, Iran. 2- Cardiovascular Research Center; Baqiyatallah University of Medical Sciences; Tehran, Iran. 3- Colorectal Research Center; Iran University of Medical Sciences, Tehran, Iran. 4- Dr. Taheri Medical Research Group, Tehran, Iran.

* Correspondence: Reza Karbasi-Afshar, Baqiyatallah Hospital, Baqiyatallah University of Medical Sciences, Tehran, Iran.

E-mail: [email protected] Tel: 0098 21 88934125 Fax: 0098 21 88934125

Received: 18 July 2013 Revised: 19 Aug 2013 Accepted: 25 Aug 2013

Abstract Helicobacter pylori (H.pylori) infection is probably the most important factor that has been associated with the development of gastric cancers in human populations. However, there are no reliable data on the prevalence of this infection in the Middle East. In this article, based on a comprehensive literature review, we aimed to evaluate the situation in this region. The literature has been searched for the incidence and prevalence of H.pylori infection by Pubmed and Google Scholar. Search was repeated for each of the Middle Eastern countries, and to empower the method, citations of each found article were searched for the related studies. Seventy seven reports from the countries of the Middle East region had been reviewed and they all indicated a high rate of infection either in the general population or in the dyspeptic patients, the rate seemed to be higher in patients with dyspepsia, in patients with histologically confirmed gastritis and in patients of older age groups. Keywords: Hpylori, Gastric cancer, Middle eastern Caspian J Intern Med 2013; 4(4): 745-753

.pylori infection is probably the most important factor that has been associated H with the development of gastric cancers in human populations. Since its isolation in 1982, evidence for its substantial casual role in the pathogenesis of gastric cancer has substantially increased. H.pylori is a gram-negative bacillus that colonizes the stomach and is probably the most common chronic bacterial infection worldwide (1). Evidence suggests that communities with a high prevalence of stomach cancer commonly have a high rate of infection with H.pylori infection and it has been suggested that the observed decrease in the incidence of gastric cancer parallels the decreasing rate of the prevalence of H.pylori infection, especially in the developed countries (2, 3). Nevertheless, controversial reports, especially from African countries where despite the high rate of H.pylori infection, gastric cancer has a very low prevalence, making it hard to conclude on the significant role of H.pylori infection on the incidence and prognosis of gastric cancers (4). On the other hand, in the largest study with the most powerful methodology on the subject, a prospective cohort of 1526 Japanese patients with non cancerous gastric and duodenal pathologies was conducted by Uemura et al. which demonstrated that patients who were positive for H.pylori infection in the study initiation was significantly more likely to develop gastric cancers (mean follow up of 7.8 years) (5). The Middle East is an intermediate prevalent region regarding stomach cancers, but the rate of H.pylori infection in this region is high (6). Nevertheless, several risk factors associated with this infection have been identified as predictors of gastric cancers in this region (7). There are several studies investigating H.pylori infection and its surrounding issues by Iranian or Middle Eastern researchers (811). Unfortunately, in the current literature, there is not a comprehensive literature review representing our evidence-based knowledge on the prevalence of H.pylori infection and its potential associations with dyspeptic symptoms in Iran and in the Middle Eastern countries. In this literature review, we aimed to evaluate the situation of Iran and the Middle Eastern countries regarding H.pylori- related gastric diseases.

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Figure 1 summarizes the data of H.pylori seropositivity in the general population of the Middle Eastern countries.

Figure 1. Epidemiology of H.pylori seropositivity in the Middle East

Iran General population: The H.pylori infection rate is very high in the Iranian general population (12, 13). In population- based study performed through 2001 – 2002 on 1011 people in Ardabil, where the incidence of gastric cancers hits a peak among all Iranian provinces, about 90% of adults aged 40 or older were reported to be infected diagnosed with histopathology and rapid urease test (14, 15). In a large population-based study of serology of 2326 people in Tehran, the overall reported infection rate was 69% which was directly correlated with age (16). In Babol, near the Caspian Sea, H.pylori infection rate detected by urease breath test was reportedly 78% and 82% for men and women, respectively (17). In Rasht, another major city near the Caspian Sea, the prevalence of H.pylori infection was 83.6% (18). In Rafsanjan located in South East Iran, the prevalence of serologically positive subjects in 200 adults was 72% in men and 62% in women (19). In Nahavand in Western Iran, 71% were serologically positive (20). In a study of 1028 individuals randomly selected from Golestan Province, northern Iran, an overall prevalence rate of 66.8% seropositivity for H.pylori infection has been reported with an increasing trend in different age groups: 30.6% in 65 years old (21). In symptomatic patients: In 303 Iranian patients attending the Endoscopy unit of Taleghani Hospital, in Tehran for dyspeptic symptoms, Shokrzadeh et al. reported a total prevalence of 86.8% H.pylori infection. A very unexpected observation in this study was that the infection rate was higher in the symptomatic patients of younger age, in a way that the highest infection rate was in patients younger than 30 years (22). It may suggest that symptomatic dyspepsia is more frequently induced by H.pylori infection in the younger ages. Another study in Southern Iran on 1000 Iranian patients with dyspepsia demonstrated that 67.1% were H.pylori-infected, patients with peptic ulcer disease were significantly more likely to be H.pylori-positive than – negative (23). A study from Tabriz, Northwestern Iran investigated the prevalence of H.pylori infection in 90 patients with hereditary bleeding disorders using stool antigen test and serology. Thirty patients had a history of upper gastrointestinal bleeding (group A) and 60 patients (group B) did not. H.pylori infection rates were 23 (77%) of patients in group A versus 31 (52%) in group B, respectively serologically and 23 (77%) vs. 33 (50%), respectively by stool antigen test, demonstrating H.pylori infection a significant factor in inducing upper gastrointestinal bleeding (24). In children: The epidemiology of H.pylori infection in Iranian children is highly diverse. While in Shiraz in Southern Iran, the prevalence of H.pylori antigen positivity in the stool exam was as high as 98% in 2 year old children (25). In Rasht, northern Iran, only 40% of children aged 7-11 years were reported H.pylori positive by stool exam (26). In Rafsanjan, Southeast of Iran also reported quite lower infection rate (52% in boys, 42% in girls) although in this study, serology has been used as the diagnosis tool (19). A study on 96 children with dyspeptic symptoms aged 1-15 years old in Tabriz, north western Iran, 35.4% were positive by stool exam for H.pylori antigen, and 64.6% were positive by histology (27). In Shiraz, Southern Iran, reported that from 113 pediatric patients with abdominal pain and other dyspeptic symptoms 52% were positive for H.pylori, detected by UBT (28). Eight hundred and six adolescents aged 13-15 years from Tabriz, Iran were evaluated for the presence of H.pylori infection by stool antigen test which revealed 35.2% infection rate in this series (29). In another

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study from Guilan, Northern Iran, 103 school children with abdominal pain were screened by serology and endoscopic evaluations for H.pylori infection. In serology, 47 (45.6%) were detected positive, while in pathology the infection rate was confirmed in only 28.2% children (30). Two hundred seventy-eight children of 7-9 years old, selected by multistage random sampling in Zanjan were evaluated in 2004 for anti H.pylori antibody (IgG) which indicated the prevalence of 52.8% of H.pilory infection in 7-9 years old children (31). Turkey: General population: The rate of H. pylori infection in Turkey is also high. A cross-sectional study of serum samples in Turkey showed a progressive rate of infection with seropositivity rates of 58.4% for individuals aged 1519; 62.6% for age 20-29; 67.6% for age 30-39; 81.3% for age 40-49; and 66.3% for over 50 years of age (32). Another study reported H. pylori prevalence rate of 66% in 20-29 years, 78% in 30-39 years, 79% in 40-49 years, 91% in 5059 years, 100% in 60-69 years, and 80% in those >70 years of age (33). An interesting study evaluating the prevalence of H.pylori infection among mothers of infected and noninfected school children found that 69% of mothers of infected children were positive for the infection compared to only 8% in mothers of uninfected children (34). A large study of 1672 individuals selected a stratified random sampling in Turkey revealed an overall prevalence of H.pylori of 77.5% among people aged between 25 and 64 years. A study on students revealed 63% prevalence of H.pylori seropositivity in this population (35). In symptomatic patients: Fifty-six Turk patients with complaints of dyspepsia were H.pylori IgG seropositivity in 82.1%, while IgA was positive in 48.2% of them (36). Another study on 1680 patients with a broad spectrum of gastrointestinal complaints in Ankara, Turkey, Seyda et al. reported a H.pylori positivity rate of 68% (37). Five hundred forty Turk patients attending a gastrointestinal outpatient clinic in Ankara underwent H.pylori serological analysis, and 273 (50.6%) were tested positive, with higher prevalence in non-smokers versus smokers (38). Ninety-six patients with bleeding ulcer and 106 patients with non-bleeding ulcer were investigated with H.pylori infection rate of 66.7% and 89.6%, respectively (39). In children: A total of 403 healthy school children aged 7-14 in an urban part of Ankara in 1990 and 2000 found the overall prevalence of H.pylori antibodies to be 78.5% in

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1990 and 66.3% in 2000 (40). Another study from Van, Turkey evaluated 275 children, aged 1-15 years suffering from different gastrointestinal complaints and 65 (23.6%) of the children were positive for H.pylori either by serology or stool exam and this positivity had a significantly increasing correlation with age. Forty-two patients with recurrent abdominal pain and 50 healthy children revealed that in 71.4% and 64% cases, H.pylori infection was seen respectively which showed no difference (41). In Izmir tested sera of 226 healthy children showed that 120 (53%) of them were positive for H.pylori IgG (42). In Istanbul, H.pylori infection rates were 42% in subjects 15 years who had undergone endoscopy for the diagnosis of abdominal pain or discomfort were included into the study, and finally 69.9% of patients were confirmed as H. pylori positive (76). Jordan: In symptomatic patients the biopsy specimens from gastric antrum have been achieved from 250 patients with abdominal pain, epigastria pain, vomiting, or heartburn, and were tested by PCR for the presence of H. pylori infection, and 110 out of 250 (44%) were detected positive for the infection (77). Bahrain: In symptomatic patients, all the 57 patients with dyspeptic syndromes attending gastroenterology clinics in Bahrain were seropositive for H. pylori infection by IgG test (78). Yemen: In symptomatic patients with chronic dyspepsia the prevalence of H.pylori infection in two studies were reported between 75%-82.2% (79, 80). In children: Five hundred seventy-two healthy children aged less than 10 years were assessed for the prevalence of H.pylori in Sana’a, Yemen, and finally 9% of them were detected as H.pylori seropositive (81). Kuwait: In 204 symptomatic patients with gastrointestinal symptoms, H.pylori infection was detected in 96.6% of the patients (82). In 362 patients with dyspepsia, 49.7% were positive for H.pylori and the percentage increased with age (83). More than 96% of 32 two patients with nodular gastritis had seropositivity for H.pylori (84). Another study of 200 Kuwaiti patients referred for endoscopy, overally 85.5% patients were confirmed H.pylori infected. Three hundred forty-five consecutive patients with symptoms of dyspepsia were screened for H.pylori infection by gastric biopsy and serum examinations and finally 228 (66%) were labeled as H.pylori positive (85). Tunisia: In children: One hundred ninety-one Tunisian healthy children were studied and the H.pylori infection rate was 30.4% (86). In another study, a total of 1055 first-grade primary-school pupils were included in a cross-sectional

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study for determining the H.pylori IgG positivity rate. The prevalence of H.pylori infection was 51.4% (87). Lebanon In children: Four hundred and fourteen children aged 1 month to 17 years of different socioeconomic standards were selected for H. pylori antigen testing in stool. The prevalence of H .pylori infection was %21 (88). In conclusion the incidence of H.pylori infection in the Middle East is high, and needs attention. The prevalence of H.pylori infection in most of the studies seems higher in symptomatic individuals compared to asymptomatic people. Moreover, the patients with histopathological evidence for gastritis are more likely to be H.pylori positive than those without. This comprehensive review also showed that several countries did not have research data in some of the epidemiological aspects of H. pylori infection, and this would be a priority for the scientists of those countries to direct their researches to evaluate these issues in their countries.

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Helicobacter pylori Infection in the general population: A Middle Eastern perspective.

Helicobacter pylori (H.pylori) infection is probably the most important factor that has been associated with the development of gastric cancers in hum...
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